T Nation

On TRT, Still High E2, New ED Symptoms

New to this site, so bare with me. I’m 28 yrs old, and started TRT approx 8 months ago from a specialist. Went into the clinic as a general check up, as I’ve been having symptoms of low test. They did a full blood test, and came back with this back September 2018.

Everything was up to par;
DHEA: 15.8 umol/l
PSA: 0.7 ug/l
FERRITIN: 228 ug/l
HOMOCYSTEINE: 7.2 umol/l
VITAMIN B12: 384 pool/l
VITMAN A: 1.8 umol/l
FREE T3: 4.9 pmol/l
Etc.

And these were my original Test and Estrogen:
FREE TEST: 275 pmol/l
Estradiol: 205 pmol/l (55.84 pg/ml)

As you can see, my E2 was through the roof, so the Dr. decided to start with arimidex, and see if we an lower it, in turn will boost my test. We started on 1mg of Arimidex per week.

Checked blood levels again in 8 weeks, and they were worse:

FREE TEST: 255.9 pmol/l
Estradiol: 195 pmol/l (53 pg/ml)

So E2 barely went down with 1 mg arimidex per week, and my test is dropping. So the Dr. decided to go on the TRT route, and start with a small dose of 50 mg of Test E per week, just to boost my test a little, without trying to chase the estrogen. Start HCG injections Sub Q at 250iu twice a week because I want to have kids in the near future. He also tripled my Arimdex dose to 3 times a week to lower my E2.

Checked levels again in 8 weeks, with little to no improvement on libido. Definitely got morning wood back, very strong, but almost a roller coaster as it came and went through out those weeks.

FREE TEST: 357 pmol/l
Estradiol: 204 pmol/l (55.57 pg/ml)

Now my test has improved a little, but my estrogen has jumped up again, even on 3 arimidex per week. The estrogen probably went up because I introduced more test in my body, but it’s a small amount, and from what I’m reading, 3mg of arimidex per week should definitely drop my E2 levels.
Now the Dr. decided to try another AI called Letrozole at 1mg EOD. Thinking maybe I wasn’t fully responding to Arimdex.

Went for checkup again in 8 weeks, now with more diminishing libido, and erectile function not up to par. (Half hard, troubles keeping a full erection during sex)

FREE TEST: 610.6 pmol/l
Estradiol: 180 mmol/l ( 49.03 pg/ml)

So now my test is higher and up to standards, I’m still struggling with getting my estrogen into “normal” levels. And my symptoms have been getting worse. Definitely lower libido, the morning woods have disappeared, and incident of ED. So the Dr. again presisited until we get that estrogen down, it still could cause these symptoms. So he added arimdex back in at 1mg twice per week, ontop of the letrozole at 1mg EOD.

Here is my most recent results:
FREE TEST: 622 pmol/l
ESTRADIOL: 158 mmol/l (43.04 pg/ml)

At this point, I’m ready to give up and stop all meds and treatment. Even with the E2 declining slowly in the right direction, I feel like my symptoms are just getting worse and worse. I don’t remember the last time I had the urge to masturbate. Tried to have sex with the girlfriend multiple times, with total ED. Which in turn, is giving me anxiety and depression because I can’t rise to the occasion for my girlfriend. I’m confused on why this is happening, the theory behind lowing my E2 should help, but even with all these AI’s, my symptoms are worse than I started. Before any treatment, I never had ED before. Maybe slight decrease in libido, and maybe not up to full mask every time we have sex. So I’m questioning if I should continue treatment, in which the Dr. insisted taking the letrozole every day at 1 mg, and 1 mg Arimdex twice a week. Or I completely stop, hoping my horomones will find a balance to even go back to what it was before. Any thoughts or experiences on this will help, whether I stick it out and keep lowering my Estradiol to optimum (Dr wants around 75 mmol/l, 20 pg/ml), or stop all treatment because the symptoms are worse.

Good lord, There is no such thing as boosting your natural T. When you take T your natural production shuts down. I am sorry but your doc doesn’t seem to have a clue what he is doing.

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I’m sorry, I’m probably describing it wrong. I know I’m not boosting my natural T. The HCG is the stimulate the testes to keep working, but they wanted to start a low dose of test to see how I’d react, before they up the dose, if needed. Which I’d prefer rather that starting with a large dose and further elevating my estrogen levels.

Please provide lab reference ranges, I have no idea where your Free T levels stand without a reference range because different lab companies have their own ranges.

Dude your doctor is failing the understand the basics of the HPTA or Hypothalamus-Pituitary-Testes-Axis, TRT shuts down the testosterone production inside the testicles and you are relient of the injectable testosterone which is a very low dosage. I’ve never seen a man succeed on TRT at this low of a dosage!

HCG can boost testosterone and estrogen a little, but also estrogen and if you’re finding it difficult to control estrogen, please note anastrozole cannot effect E2 inside the testicles. You must lower the dosage because it won’t matter how much anastrozole you throw at the E2 problem.

As it stands now with your current doctor you stand no chance of success on TRT, we often see doctors getting this TRT wrong. A lot of men find they feel better without HCG, you can restart it later when trying for kids and also add FSH injections. The latter is a game changer when HCG alone isn’t enough to increase sperm production.

I would make a stab in the dark and say your levels are low, not high.

@systemlord Sorry, here are the lab reference ranges:

ORIGINAL FIRST LAB RESULTS:
DHEA: (Optimal:12-16 umol/L)= 15.8
PSA: (Optimal: <4.6 ug/L)= 0.7
FERRITIN: (Optimal: 50-300 ug/L)= 228ug/L
HOMOCYSTEINE: <8 umol/L= 7.2
VITAMIN B12: >300 pmol/L= 384
VITAMIN A: (Optimal: 1.5-3.5 umol/L)= 1.8
FREE T3: (Optimal: 3.5-6.5 pmol/L)= 4.9
FREE T4: (Optimal: 9.0-23.0 pmol/L)= 16.0
TSH: (Optimal: 0.20-4.00 mU/L)= 1.48
ESTRADIOL: (Optimal: 30-75 pmol/L) = 230pmol/L Misread my first E2 results
FREE TEST: (Optimal: 350-700 pmol/L)= 275 pmol/L

MOST RECENT LAB RESULTS: (8months later)
FREE TEST: 622 pmol/l
ESTRADIOL: 158 mmol/l (43.04 pg/ml)

I understand what you are saying about the HCG injections, and how the AI’s will not lower those estrogen levels. The specialist gave me the option to start with just Test, or include HCG, based on the fact that I do want to have kids in the near future, and I don’t want to risk testicular atrophy. He did state I can start HCG a lot closer to when I want to have kids, and my sperm count and fertility will return. I did not know though HCG would hinder my results, I always thought with stimulating your natural test, it would only be beneficial.

My main concern is, could it be possible that maybe my “optimal” range for estrogen could be quite higher than normal? From the results, in theory, symptoms should be getting better, with my E2 lowering, and my Test increasing. But I feel like I am worse than I started… and there was a point where my morning woods were back, and erections were good. Could my ‘‘sweet spot’’ be possibly a higher estrogen/test ratio? Or is that very uncommon, and majority of men feel better with E2 within optimal limits?

The experienced doctors are finding the optimal ranges to be Free T at the top of the ranges or higher. I don’t see how levels in the low normal ranges can be consider optimal.

I understand what your saying, but my lastest test results for Free Test was 622 pmol/L, definitely a change from the start at 275 pmol/L, with only 50mg of test per week. I could bump it up to 100mg per week, splitting more frequent doese to prevent E2 levels from rising. But I’m curious if I should stay on the AI’s, and keep lowering my E2 levels because they are high according to standards. Or stop, and see if they will level out. For some reason, I’m feeling like I was feeling better when my E2 levels were higher than they are now.

@enackers do you happen to have any insight on my post? I’ve been researching alot of forums, and you seem to preach a lot about how it’s okay or even best to let your E2 run higher if you were feeling better.

Ryan

Form my reading I found that it’s best to allow the body to convert T to e2 naturally. If one has symptoms form estrogen then the body is not efficient and needs work. These are alarms going off under the guise of symptoms.

Lab ranges are shit. Ffs they still test men with woman’s estrogen lab tests. What is high e2? Where’s the research saying anything above 50 is bad. On the contrary we know for a fact that around 20 and lower men start having horrid sides. Compare low to high e2 in men and you easily see the difference in how extreme the sides are.

Docs who use ai simply want that option for their patients because they are afraid patients will experience sides. Now many of the docs say as needed: look at dr saya at defy. He doesn’t say “take ai if estrogen hits 50”… he says as needed.

The wonderful and late Dr. Crissler said the same thing. I do not prescribe based on numbers. I only give ai if the patient has symptoms. He has a great video with jay c and you can find it if you look.

Watch this video. You’ll get the answers you are looking for. This is doctor is boss in the medical community. He trains other doctors in HRT and is probably one of the most sought after docs in the nation. Check out world link medical he has articles there.

Here is Dr.Says who still prescribed ai but he pretty much says don’t take ai unless you have symptoms .

I posted a long post a while back summarizing thoughts on the subject. Unfortunately, it was part of a thread where a member became hostile to other members and the entire thread was subsequently deleted.

In essence it all boils down to two words: SYMPTOMS and BALANCE

Symptoms indicate and guide (to an astute and experienced practitioner) the need for any treatment (whether it be TRT in general, AI, thyroid treatment, adrenal support, etc) and balance rules the entire human body, with hormones being no exception.

We know that there is risk with too low and too high of levels for any hormone in a biological entity (is E2 the only exception in the human body?). Where is that line of too high? - no one knows and to complicate further that “line” is likely variable from patient to patient dependent on countless other variables (SHBG, prolactin, DHT, thyroid function and TBG, phyto amd xenoestrogen exposure, alcohol, genetics, receptor regulation, etc, etc).

Anastrozole is a tool in the toolbox. Some patients need it, many don’t. Sometimes it is thought it is needed and subsequently determined it wasn’t. Whereas sometimes it is thought it wasn’t needed and subsequently determined it was. Balancing hormones is a symphony, not a solo, and even the brightest minds in our field are challenged to BALANCE all of the relevant variables and moving parts.

As mentioned in a post above, after participating in the hormone dance for so long, with so many patients, often some intuition begins to develop as well (for all practitioners)…this is the “art” you here spoken of to augment the science.

Also we keep in mind the difference between a medicine and poison is a matter of dosage. Vitamins, supplements, medications, etc can virtually all present toxicities (poison) at high levels and high dosages…thus when ANY medication is used, lowest effective dosage is key (those poor guys taking anastrozole 1mg daily - or similar…).

I’m in agreement Anastrozole is over-prescribed and, worse, often in too high of doses as part of a standing protocol or “cookie-cutter” approach. In fact, even my dearly missed pal Dr John was more aggressive, in many instances, with his anastrozole (0.5mg commonly).

I don’t want to comment in too much depth on that topic, as I am still grieving personally and reconciling the loss of a friend, but everything is not always as it appears on the surface. Dr. Crisler “consulted” with me for his personal hormone treatment and it was my name on his RXs. He did most of his own personal driving, but I ultimately discussed and approved for him while, as noted, “first doing no harm”. Fact is he had been on and off of anastrozole many times in the past, for varying periods of time, only to find himself back on due to various symptoms he would convey (nipples, irritability, excessively emotional, feeling “like a little girl” as he would playfully put it). He would feel better sometimes on, then worse, sometimes better off, then worse…there were many other factors at play (as there are for all of us). The fact he decided to broadcast his most recent anastrozole variations (as opposed to the many occasions of on/off prior) was due to some outside forces (and outside sources of angst) that were troubling him. I don’t want to get any deeper on this topic, but John was troubled by some recent events in his life, which bothers me as well.

Regarding anastrozole/estradiol management - we aim to resolve symptoms, we aim to achieve balance with the hormonal symphony (more challenging in some cases than others), we aim to use our intuition when applicable, and we accept the reality that no one has all of the answers to all of the questions at this time (particularly on this topic). I love all of my patients who need anastrozole just as much as I love those who do not need it.

I will leave this thread be for now as I continue to grieve the loss of my friend and colleague, the great Dr John Crisler.